Opportunistic and Organized Cervical Cancer Screening: Impact on Lesion Severity and Surgical Outcomes in 9830 Cervical Conizations

Objectives: To assess the impact of organized (OgS) versus opportunistic screening (OpS) on grade, extent, and surgical management of cervical lesions, and to evaluate human papillomavirus (HPV)-based versus cytology-based screening within OgS. Methods: This retrospective study analyzed 9830 women undergoing conization (1992–2021). Data included screening modality, histology, cervical intraepithelial neoplasia grade 3 (CIN3) linear extension, and cone volume. Statistical analysis employed chi-square test, Student’s t-tests, Cochran–Armitage test for trend, and Firth’s penalized multivariate logistic regression to identify independent predictors of invasive disease. Results: Of 9830 patients, 5097 (52%) were referred from OgS and 4733 (48%) from OpS. OgS patients were significantly older (40.0 vs. 37.0 years; p < 0.001). In the final decade, OgS achieved a significantly lower rate of invasive carcinomas compared to OpS (1.1% vs. 2.7%; p < 0.001). Mean CIN3 extension and cone volume were significantly lower in OgS (6.5 mm; 1150 mm3) than in OpS (7.1 mm; 1580 mm3; p < 0.001). Within OgS, HPV-detected CIN3 lesions were smaller than cytology-detected ones (5.9 vs. 6.4 mm; p < 0.001). Long-term analysis showed a borderline downward trend in invasive cancer for OgS (p = 0.089), whereas OpS remained stable at higher risk levels. Multivariate analysis confirmed the screening model as an independent predictor of invasiveness: OpS was associated with a two-fold increased risk of invasive cancer compared to OgS (adjusted odds ratio: 1.99; 95% confidence interval: 1.41–2.83; p < 0.001). Conclusions: OgS identifies high-grade precancers earlier and with smaller excisional requirements. OpS is associated with significantly higher invasive cancer rates and larger conizations. Multivariate data reinforce OgS as a superior framework, effectively halving the risk of invasive disease compared to OpS.